From the medical academic conferenceSpecialist registrar grade is causing problemsDisincentives to an academic career spelt outLabour party's plans for student financeThe conference ..From the public health conferenceYoung people need a better dealPossession of private handguns opposedContinuing education must be properly resourcedGeneral practice could be underminedThe conference..From the senior staffs conferenceProposal for a closed contract defeatedNon-consultant career grades need a better dealPrivate finance initiative deploredIntensive care needs adequate staffingThere must be local manpower adviceThe conference ..BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7045.1543 (Published 15 June 1996) Cite this as: BMJ 1996;312:1543
- Linda Beecham
From the medical academic conference
Academic doctors warn of continuing crisis
Medical academic staff have warned of the danger to patient care of the continued underfunding in the NHS and the universities. At the conference of medical academic representatives last week the chairman of the BMA's Medical Academic Staff Committee, Dr Colin Smith, attacked the Department for Education's view that there was no correlation between funding levels and the quality of doctors produced. “Poorer resources mean poorer products, poorer research, poorer teaching, and poorer doctors.” There was now an acknowledgment that there was a crisis and the BMA would be giving evidence to the Dearing review on higher education and the Richards inquiry into disincentives to careers in academic medicine.
The Committee of Vice Chancellors and Principals highlighted the crisis at a national press conference, pointing out that any further reduction would mean fewer staff, poorer undergraduate teaching, less research, fewer academics working in the NHS, and a greater workload for those remaining.
Despite the increasing pressure to do more and more research, there were fewer funds and grants—nearly three quarters of alpha rated grant applications were not funded. Dr Smith called it a tragedy that the Medical Research Council would no longer fund intercalated BSc degrees. So medical academic staff faced a “triple whammy”— reduced research funding, reduced teaching funding, and reduced clinical funding. “There is pain,” Dr Smith concluded, “and it will get worse.”
Specialist registrar grade is causing problems
The conference was able to quiz a health department official on its worries over the introduction of the specialist registrar grade, which will replace the existing registrar and senior registrar grades. The chairman of the MASC told the meeting that his committee believed that it was a good idea to rationalise training, but because of the dual role of the NHS and the university it was not possible, in many instances, to fit clinical academic staff into the training rotations.
Although the conference passed a motion that academic medicine was “threatened with extinction as a consequence of the Calman training programme,” Dr Robert Hangartner, senior principal medical officer at the NHS Executive, said that the executive did not believe that the implementation of the proposals for specialist training would be detrimental to research and academic medicine. “We recognise the importance of research,” Dr Hangartner said, “it will remain paramount.”
The Calman report on specialist medical training was about flexibility and not rigidity and although the majority of doctors wanted to pursue a clinical career it also recognised the need for some doctors to do first class research and academic medicine.
He agreed that the proposals would fundamentally change the way that doctors were trained but the pace of the changes would be driven by the capacity of the NHS to absorb them. At present there was a period of transition; he anticipated that the changes would be completed by the year 2000.
There was some confusion over the national training number, which would be unique to the individual. It would be transferable between regions, and doctors who went into research would be able to take the number with them. There was more than one route on to the specialist registrar and Dr Hangartner reported that the NHS executive was pursuing this issue with the Special Training Authority to make sure that the routes were clear. It should be possible for doctors who wished to do research to do so as part of their training and there would be opportunities to discuss this in the Richards and Dearing reviews and in the routine meetings between the Department of Health and the BMA.
Dr Colin Smith suggested that the year 2000 might be too late as many of the lecturer posts, which formed the basis for many academic careers, were disappearing and being replaced by basic science posts which would attract more funds.
A professor of radiology at Bristol University, Professor Michael Rees, pointed to the difficulty of motivating young doctors who were already highly motivated. It was difficult to break into a five year training period. The research would have to be very focused and more funding would be needed.
Disincentives to an academic career spelt out
Speakers at the conference were quick to respond to Sir Rex Richards's request for suggestions about why a career in clinical academic medicine was unpopular. Sir Rex, a former vice chancellor of Oxford University, is chairing a task force, which is due to report to the Committee of Vice Chancellors and Principals by the end of 1996 on the recruitment and retention of clinical academic staff. It will take into account the effects of the NHS workload on the ability to carry out teaching and research; the effect of changes in specialist training and workforce planning; the changes in university and NHS funding systems; and the effects of European Union directives on recruitment and on teaching and research.
Asked why the task force was composed of “the great and the good,” Sir Rex said he hoped that this would mean that the task force's deliberations would be taken seriously. He hoped that the result would be a calculated and objective view of the position. There had been only one meeting so far and much of the evidence was anecdotal. The next step would be a detailed questionnaire to deans of medical schools, due to go out before the end of June. A member of the task force would visit each medical school.
The deans will be asked for the number of tenured academic staff by specialty over the past five years; the average number of candidates with comparable figures for NHS posts; the number of vacancies in the past year; the age range of academic staff and the difficulty in recruitment; the distribution of sessions between service commitment, research, and teaching; the number of medically qualified staff in preclinical departments; and details about salaries.
Sir Rex said that medical schools would be asked to arrange for a group of young academic staff to meet the task force and a further questionnaire might be sent to a random sample of aspiring academic staff. He appreciated that the position was changing all the time and the task force might propose a further survey in two years' time.
Dr Colin Smith, chairman of the MASC, suggested that the task force should determine who it met and not leave it to the deans and that it should talk to doctors in the NHS and ask them why they had not followed a career in academic medicine.
A lecturer in forensic pathology in Sheffield, Dr Chris Milroy, said that Sir Rex should ask senior house officers the same question and look at where clinical academic posts had been disestablished to create posts that would bring in research funds. He also pointed out that many specialties were entirely university based and run by clinical academic staff who could not do research or teach while caring for patients.
Professor Michael Rees, professor of radiology at the University of Bristol, said that trusts should be asked if they regarded clinical academic staff as value for money and whether they were prepared to provide funding.
Dr Nigel Klein from the Institute of Child Health said that he was worried that if the questions over the specialist registrar grade were not sorted out an entire group of junior academic staff would be lost. Universities and trusts should be asked what plans they had for those doctors who wanted to take a year off to do research.
Labour party's plans for student finance
In its document, Lifelong learning, the Labour party proposes that university students should repay their maintenance costs over a 20 year period in relation to their incomes. Addressing the conference last week, the party's spokesman on higher education, Mr Bryan Davies, emphasised that tuition would be free. Although student finance was only a small part of the document, it had been highlighted and Mr Davies said that the Labour party was not prepared to put up with the current system of student support. Postgraduate students received little support and the burden of repayment fell on young people at a difficult time in their careers. The Labour party would be asking the Dearing review on higher education to look at the whole subject of student support.
When Dr Stephen Hajioff (St Bartholomew's and the Royal London) pointed out that most doctors would be working for a monopoly employer in the public sector, where salaries were lower, Mr Davies said that many people would envy doctors, who generally had a guaranteed career with a guaranteed level of income.
To the criticism that any form of repayment would be a disincentive and would favour students from better off families, Mr Davies pointed out that Britain was alone in providing maintenance support for students. Australia had introduced a repayment scheme in 1989 and this had resulted in considerable funds accruing to universities. The severe cuts in higher education in Britain, partly caused by bad budgeting, were causing problems and the Labour party was campaigning against the cuts.
Mr Davies said that he was concerned to hear that there were so many unfilled clinical chairs; the Labour party would propose to the Dearing review that it should review pay arrangements in an attempt to help recruit and retain staff. Although there should be some flexibility, the Labour party opposed local pay bargaining.
It was critical, he said, that research was properly funded. He believed that the present government had sold higher education short. He could not promise to transform the position overnight, but the Labour party would aim to repair the damage of recent years.
The conference ..
Opposed the possible introduction of top up fees for medical students or a graduate tax
Considered that an all graduate entry into medicine was desirable (carried as a reference)
Resolved that any restriction of access to confidential information should recognise the need for, and facilitate access to, research
Applauded the increasing trend for undergraduate medical teaching in primary care but demanded appropriate funding
Called for the skills required for teaching to be incorporated into medical education and training at all levels
Urged the BMA to consider the implications of the proliferation of medical type degrees obtained by non-medical graduates
Called on the BMA to investigate whether there was a need for the establishment of a new medical school in Britain.
From the public health conference
Income inequality is a health issue
The government should address inequalities in income as a health issue as well as an economic one, the public health conference resolved.
Dr Mark Lambert, from Yorkshire, said that income inequity was at its worst in Britain since the second world war and that this presented “one of the main obstacles to the improvement of public health in the 1990s.”
The debate took place in the light of increasing evidence and advice on the issues of inequality from sources including the BMA, the King's Fund, and the University of York. Several representatives spoke of how the promised “trickle down effect” had failed to materialise, resulting in a widening gap between rich and poor.
The chairman of the CPHMC, Dr Stephen Watkins, called into question the validity of the government's approach even from an economic viewpoint: “Research shows that inequality in income actually adversely affects the performance of an economy. So there is very little justification in increasing this inequality in the belief that there will be a trickle down effect. An economy that can only be sustained by damaging the health of the people is not a healthy economy.”
Dr Sandy Macara, chairman of the BMA council, said that Britain should be working towards a policy of health which started with equity. In an impassioned speech, he declared: “The NHS does the reverse and drives people out to private practice to get the treatment they deserve. Managers are forced to tell consultants which patients they are allowed to treat in financial terms. And where are our real working links with local authorities in community care? We have no levers or control any longer.”
Dr Macara said that the government should introduce a coordinated policy within every department—whether housing, education, employment, transport, or recreation—in relation to health, and especially inequalities. “Every sector of human activity would have to be addressed in terms of health,” he said.
Young people need a better deal
Representatives backed a plea for adolescents to get a better deal. They called for the establishment of non-judgmental outreach services “aimed at rooting health in youth culture.” And they deplored the recent suggestion that young people be subject to curfew.
The meeting was also clear that, in view of local management of schools, the school health service “must be reshaped and repaired so as to provide effective public health advice to schools.”
Dr Stephen Watkins said: “Many health service managers think school health services are a relic of the past and something you can easily get rid of.”
The meeting expressed its disappointment that the spirit of the recommendations of the Child Health Working Party was not being adhered to and unanimously agreed to urge the health department and NHS trusts “to take proper account of the experience of senior clinical medical officers when appointing consultants in community paediatrics.”
Dr Vasco Fernandez (Oxford) said that the working party had for many years deliberated the way forward for community health doctors. “Sadly as soon as its report was published we were hit by the purchaser-provider split in the NHS, which gave trusts significant control over the implementation of guidance from the Department of Health. We have seen many trusts find imaginative ways of not appointing senior clinical medical officers to consultant posts in community paediatrics.”
Possession of private handguns opposed
In the wake of the recent mass shooting tragedies at Dunblane in Scotland and in Tasmania the meeting passed a motion that “the private possession of handguns should normally be prohibited.”
Dr Colin Hamilton (Northern Ireland) warned against mass gun ownership and said that in Los Angeles the commonest cause of infant death was gunshot wounds. He also said that he could not see any need for posession of automatic weapons: “There is no Olympic tommy gun event. There is no need to shoot 50 ducks a second.”
The decision to pass the motion followed some debate about whether people should be allowed to possess handguns provided that they were kept secure in an armoury rather than in their homes, or whether there should be a ban on ownership at all.
The chairman of the CPHMCH, Dr Stephen Watkins, said: “There is no doubt that widespread availability of guns represents a public health hazard. There is no reason for them to be kept at the homes of people using them, even for sport. But this is not intended to be a motion to ban the sport of pistol shooting.”
Continuing education must be properly resourced
The meeting felt strongly that community health doctors should receive the same funding for continuing medical education (CME) as other career grade doctors. Representatives welcomed the requirement for CME but also agreed unanimously to urge the Department of Health to ensure that it was appropriately resourced. This meant not just payment of study leave but also resources to provide for cover, they heard.
Dr Philip Hambly (Wales) said that there was no proper recognition of the need for CME, which required protected time and protected and full funding. He called for a change of attitude by purchasers and managers: “There is going to be a lack of service provision while people go for CME and that has to be accepted.”
Dr Vasco Fernandez (Oxford) said that study leave was only one part of CME and he warned: “We need to be very careful it is appropriate to CME. Often it is a great day out, but in effect it does not further career progress or have anything to do with local service input. We must be objective.” He said that CME need not involve formal lectures, and could often be obtained through informal discussions or during a meeting.
Dr Gillian Painter (community health doctors subcommittee) agreed, saying: “There is a lot of CME that goes on internally that does not need extra funding.”
The meeting also invited the BMA's board of education to review continuing and postgraduate medical education and to propose a mechanism to establish “first class, broad based support for CME for doctors across the country.”
General practice could be undermined
The “alarming” decrease in numbers of entrants to general practice threatens to undermine the primary care structure of the NHS, the conference agreed. Representatives called for urgent government action to clarify the reasons for this and to reverse the trend.
Dr Peter Tiplady (Northern) described British primary care as the best in the world and said that the contribution of general practitioners to the medical scene was inestimable: “Primary care has been the jewel in the crown of the NHS and must be again.” But general practitioners who used to get 20 applicants for a job now say that they have difficulties in getting a shortlist, said Dr Tiplady.
Dr Anne Rodway, who represented the General Medical Services Committee, said that as far as a primary care led NHS was concerned, “Without adequate manpower and resources, primary care is not going to be able to lead anybody anywhere.” She advocated a change in the format for partnership and premises to accommodate the changed attitude among young doctors, who no longer wanted a commitment for life.
Requested the BMA's board of science to initiate a study of the long term implications of domestic violence on the health of the family
Called for a food ministry separate from the Ministry of Agriculture in the light of numerous recent food safety concerns
Supported the continuing role of public health physicians as independent voices and called for this freedom of speech to be restored to public health doctors working in regional offices
Deplored the cuts in family planning services which are leading to a reduction in choice for patients
Expressed concern at the discrepancy between the projected number of public health medicine trainees and projected consultant vacancies and called for future trainee numbers to be linked to known consultant posts
Deplored the decision to include the employment costs of public health doctors in the management costs of health authorities, and called on the BMA council to try to have the situation corrected.
From the senior staffs conference
The DGH is sustainable but must change
The Central Consultants and Specialists Committee has set as its major task in the coming session an examination of the future shape of the hospital service, particularly the district general hospital (DGH), which many people believe is under threat. The senior staffs conference, however, disagreed that the DGH was no longer sustainable, but agreed that the future shape of hospital services would vary according to local area need.
Mr John Carvell, an orthopaedic surgeon in Salisbury who proposed on behalf of the agenda committee that the concept of the DGH was no longer sustainable, maintained that the DGH had to change to meet the demands placed on it. It was no longer possible to provide every aspect of care in each hospital; consultants had to be prepared to travel and provide cross cover. Consultants were already providing clinics for general practitioners, and day surgery was increasing. The DGH had to be large enough to provide the services for the community. He did not believe that it could survive in its present form.
CULTURE OF COOPERATION
He was supported by Dr James Appleyard, a paediatrician in Canterbury, who pointed out that DGHs were intended to serve populations of 250 000; now districts of 110 000 wanted their own DGH and that was wrong. It was not possible to provide that degree of service; there had to be a culture of cooperation and networking with teaching hospitals. The most important aspect, that specialist services were provided locally, had to be retained.
But the majority of speakers supported the DGH. Where was the evidence that it was not sustainable, Mr David Gatehouse, a consultant surgeon in Shotley Bridge, asked. Dr Bob Buckland, a consultant anaesthetist in Winchester, agreed that not everything could be provided at every hospital, but the decision had to be taken on clinical grounds in the best interest of patients. Consultants should not let the future shape of hospitals be determined by a discredited contracting system. Dr Tim Webb from the Welsh Regional Consultants and Specialists Committee said that DGHs had to stay in the rural areas.
”The DGH can survive, but it will be at a price,” the CCSC chairman, Mr James Johnson, said. They could not survive as a group of mediaeval city states, occasionally going to war with each other.
The meeting agreed with South West Thames RCSC that whatever model of hospital emerged it had to have regard to local geography, transport, and population; allow rational and stable forward planning and training; allow manpower planning commensurate with the requirements of service; enable the provision of a near comprehensive service with reserves to support one or more super specialties; enable collaboration and coordination of services—for example, accident and emergency—and overall bed provision; and allow integration of terms and conditions of service for junior doctors rotating between provider units.
Proposal for a closed contract defeated
There was little support for the CCSC to explore the benefits of a closed contract for consultants despite forceful support from Mr Kanwar Panesar from the Northern Ireland Consultants and Specialists Committee. He maintained that the open contract meant most consultants worked far more than they were contracted for because of the increased workload pressures and the reduction in junior doctors' hours. “We have been exploited for a long time and we have had enough,” he said.
But Dr Robin Arnold, a consultant psychiatrist in Bristol, said that consultants were a powerful group when they acted together. “We give our professional contract up at our peril,” he said.
Dr Christopher Bayliss, a consultant radiologist in Exeter, thought that the present contract had served consultants well for 50 years. But dedicated consultants were being abused. Many trusts did not employ locums to save money and the unified training grade was not going to be a unified working grade. The contract should be maintained but consultants' job plans should be changed so that no consultant should be required to work more than 56 hours a week or be on call for more than 36 hours continuously.
The conference resolved that any consultant who agreed to be resident in exceptional circumstances did so voluntarily and that this should be recognised by an appropriate remuneration package of a minimum payment of three times the value of a notional half day per notional half day worked, together with time off in lieu.
Non-consultant career grades need a better deal
The conference criticised the abuse of many doctors in non-consultant career grades and called for negotiations for “a proper and fair career structure for all non-consultant career grades to include fair remuneration for on call duties.” Dr Bob Buckland, a consultant anaesthetist from Winchester, referred to the proliferation of non-specific grades with trusts creating their own posts on differing salaries. There was often no proper career structure and no proper route for promotion to the consultant grade. Many doctors were being inappropriately used. “Serfdom is not too strong a word,” he said.
Dr William Ryder, a consultant anaesthetist in Hartlepool, asked the meeting to add as a rider, “and to exclude onerous and unreasonable job plans.” When performance supplements were introduced for associate specialists he had been elected to the awards committee and he had been appalled by the onerous work required of associate specialists who were nominated for a supplement. One chief executive said that if the committee did not recommend an award the trust would be obliged to increase the pay of associate specialists to reflect their workload. In one instance there were 37 applicants for four possible awards.
The conference also agreed that a scheme similar to the discretionary points should be considered in the negotiations on the staff grade contract.
Private finance initiative deplored
The CCSC chairman told the meeting in his opening remarks that the issue of the private finance initiative was complex and needed to be examined in detail. It was understandable if doctors embraced the idea as the only hope of getting a new hospital. Whenever he attacked the concept he received critical letters from doctors who were getting a new hospital. This dilemma was raised during a debate on a successful motion from the Mersey RCSC which deplored “the politically driven private finance initiative leading to the creeping privatisation of the NHS.”
Any proposed capital scheme had to include an option for private finance, Dr John Kenny said. If not, it would not be considered by the NHS Executive. The advantage for the government was obvious. Capital investment could take place without using public money. He could not understand why the NHS, which was already strapped for cash, should be forced to obtain finance at less than advantageous rates.
Speaking reluctantly against the motion, Mr Brian Hopkinson, a consultant surgeon in Nottingham, said that the initiative might be the only way that some consultants could get the extra services and equipment they needed. “We ought to examine this carefully and not throw the baby away with the bath water.” The important thing was to get involved and get the terms and conditions right. The ear, nose, and throat consultants in Nottingham, he said, had expanded their facilities using private finance but had been closely involved in the exercise.
The conference also endorsed a motion from the CCSC's pathology subcommittee, which criticised the inclusion of near core and core clinical services in the private finance initiative.
Intensive care needs adequate staffing
The conference unanimously expressed its concern about the severe shortage of adequately trained doctors and nurses to staff intensive care beds and the shortfall in funding which kept beds closed. Two weeks ago the government said that 37 more paediatric intensive care beds would be provided but provided no extra money (8 June, p 1439).
Dr John Copley, from north East Thames, in proposing the motion, said that his worst experience was being told that the nearest intensive care bed was in Glasgow. The position had been alleviated by the emergency bed service providing information on intensive care beds. There were, however, still one or two patients a day who had to be referred to other hospitals. This put a strain on staff and relatives. There were some beds in his region which were funded but closed because of lack of staff. Dr Copley said that his father was a psychiatrist, his brother a rheumatologist, and his sister a general practitioner: all were struggling with often inadequate funding to provide a service.
The chairman of the CCSC's accident and emergency subcommittee, Mr Laurence Rocke, urged the meeting to support the motion. He reported that patients often had to be ventilated in the recovery room and patients were being turned away. He knew of a paediatric nephrologist who, this year, had to turn down the offer of three kidneys for children because of the lack of beds for postoperative care.
There was an easy solution, according to the CCSC chairman—“either we pay more taxes or there would be rationing.” But he was convinced that the consultants should “blow the gaff” on what was going on all over the NHS.
There must be local manpower advice
In many places regional manpower committees have disappeared and the conference called for a strong and effective advisory structure at regional level to replace the committees and the task forces on junior doctors' hours. Dr Bob Buckland, a consultant anaesthetist from Winchester, said that the local medical workforce advisory groups had not been set up and there was what he called “bottom up planning.” The regional consultants and specialists committees should make appointments to the new groups, which should have a majority of medical members. The chairman should be elected by the group and not be the regional director of public health.
The CCSC chairman told the meeting that a paper on the local groups was going to the Advisory Group on Medical Education, Training, and Staffing in July. The local groups were likely to be small and he hoped that doctors would be in the majority. They would be able to discuss with trusts where there are inappropriate manpower proposals. If that course fails the group would be able to take the matter up with the NHS regional office. Mr Johnson hoped that the groups would be able to prevent trusts from saving money by staffing hospitals without consultants.
The conference ..
Resolved that increased medical student intake must be guaranteed to secure the essential planned expansion of consultants
Believed that the grade and qualifications of all professionals involved in patient care must always be clearly apparent to patients and to referring doctors
Resolved that purchasers should ensure that contracts included ringfencing funding and adequate time allowance for continuing medical education
Believed the problem of hospital bed blocking by patients awaiting social services assessment needed to be addressed urgently by the government
Declared that it was the consultants' responsibility to refuse admission to beds if they thought that the staffing situation was unsafe
Recognised that finding a geographical bed for a patient was a responsibility for the hospital management
Was concerned by the move of clinical services from hospital into the community because of the difficulty of maintaining standards of care and of ensuring high quality training for staff
Believed that the role of the doctors' and dentists' review body was to consider evidence from the profession and the health departments and not to act as a policy forming body
Urged that the length of permit free training should allow the completion of specialist training programmes
Resolved that the numbers and proportions of doctors in non-consultant career grades working in NHS trusts should be strictly controlled.